Consultation Patient - Medical History

 

Medical history Form

Previous Operation

Diabetes

Yes
No

Heart Disease

Yes
No

Lung Disease

Yes
No

Kidney Disease

Yes
No

Allergies

Liver Disease

Yes
No

Bleeding disorder

Yes
No

Glaucoma

Yes
No

Medications

Hepatitis B or C

Yes
No

Pregnant/Breast feeding

Yes
No
 

Family history of gastroenterology or liver disease

If you have circled yes to heart disease, lung disease, kidney disease, liver disease, bleeding disorder or if you have any other medical problems please outline in more details in the space below

Height (in cm)

*Your height must be in cm. Do not include the word cm. For example just write 168 and then proceed to the next field to enter your weight. If you do not know your height in cm then you can easily Google an imperial/metric convertor

Weight (in kg)

Important Info!
*Your weight must be in kg. Do not include the word kg. For example just write 75 and then proceed to the next field to enter your occupation. If you do not know your weight in kg then you can easily Google an imperial/metric convertor

Your BMI is

Occupation

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If you do not want to send the forms electronically then click here to download a PDF version which you can print out, fill in by hand and send to us by fax 95282292 or email to reception@nagree.net